The operator of the Croydon tram network did not “fully investigate” an incident just a week before the fatal crash where a tram went too fast around the Sandilands bend and could have derailed, until after the fatal crash.

A different tram driver used his tram’s hazard brake at 5.22am on October 31, 2016 – just nine days before the derailment – and data shows the tram entered the bend in excess of 45 km/h, according to a report released on Thursday.

A shocked passenger on board reported through Transport for London’s (TfL’s) website that she had suffered injuries to her head, shoulder, wrist and finger.

The Rail Accident Investigation Branch (RAIB) said the tram was “very close” to the speed at which the tram would have overturned.

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Croydon tram crash report

“Although this tram did not overturn, this incident revealed the potential for a driver’s mistake to cause over-speeding and then overturning,” the report states.

It continued: “The driver of the tram stated that he normally applied his tram’s service brakes at the second tunnel gap but, on this occasion, missed this braking point and applied the hazard brake when he saw a bank of fog at the exit of Sandilands tunnel.

A tram travelling around the Sandilands bend (Image: David Cook)

“The incident happened in darkness and the driver was intending to follow his normal practice of identifying the tunnel gaps using the short white fences at these locations.

“On the morning of October 31 he missed the first fence, and so thought the second fence was actually the first fence.”

The driver did not report the incident, but that evening a passenger did through TfL.

“The driver of the tram knew that he should have reported the incident on October 31 to TOL control, but he chose not to,” the report states.

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“The driver stated that the primary reason he did not report the incident was because he had checked the welfare of the passengers and they all seemed unharmed.

“He also stated that he had thought that if he reported the incident TOL [the private company that runs the trams under contract to TfL] would remove him from tram driving while the incident was investigated. He also believed that some controllers had a belittling attitude towards drivers.

“The driver also thought that he did not have to report the use of the hazard brake because he had released the hazard brake before the tram came to a stop.”

The tram's two carriages were left on their side (Image: Jim Bennett)

This information was automatically forwarded to Tram Operations Limited (TOL) and was not reviewed by TfL staff.

The passenger, who boarded at New Addington, said: “As the tram went around the bend at the junction between Lloyd Park and Sandilands the driver, from my point of view, missed the bend or he was going too fast ... I was pitched to the corner of the tram and a man sitting on the other side came over on my side and pinned me to the corner of the tram.”

The RAIB said the limited data storage on the on-tram data recorder (OTDR) that day would “almost certainly” have been overwritten by the time the passenger made her complaint.

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Evidence may have been available from “loop data” but is not available for many locations and TOL’s investigation focused on obtaining CCTV images.

A TOL staff member saw the email sent by the passenger the day after it was sent and it was entered onto a database of customer complaints.

Two trams were identified as possibly being involved and the next day the staff member sent an email back asking for more information.

Three days later, on November 3, the person dealing with the complaint identified the tram and driver.

A map showing where the crash happened (Image: RAIB)

“No further action was taken at this point because the potentially serious nature of the incident was not understood,” the report said.

When a non-urgent request has been made, the tram CCTV is normally downloaded overnight while the trams are in the depot.

If an urgent request is made, a tram can be taken out of service and returned to the depot to have its CCTV system downloaded at any time.

The following day, on November 4, the staff member requested the CCTV to be downloaded. This was attempted overnight on November 4 to 5 when it was found that footage from October 31 had been overwritten.

TOL’s procedures require its drivers to report the use of the tram’s hazard brake and it had sent a letter to all of its drivers three years previously reminding them.

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TOL did not speak to the tram driver involved in this earlier incident until the day after the fatal tram crash.

The report does not mention what, if any, action was taken against the driver.

The RAIB said TOL said even if it had spoken to the driver it is “unlikely” it would have taken any action relating to other drivers.

Investigators added it cannot be known for certain if a briefing to drivers or any other action would have prevented the fatal crash – but if TOL had understood the tram was in fact close to overturning, it is likely that action would have been taken to avert the risk and it could have been reported to the RAIB.

Several of the safety recommendations the RAIB report makes relate to some of the concerns raised by this incident, including improving the effectiveness of identifying complaints and fostering the creation of a “just culture” in which staff are more likely to report incidents and safety-related concerns.